Provider Demographics
NPI:1912656968
Name:EHRENSTROM, NICOLE (MSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:EHRENSTROM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BARTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:1 ED GARDNER PL
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1677
Mailing Address - Country:US
Mailing Address - Phone:618-939-3060
Mailing Address - Fax:
Practice Address - Street 1:1 ED GARDNER PL
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1677
Practice Address - Country:US
Practice Address - Phone:618-939-3060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140296811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical